CLM-2026-020788
Lakeside Medical Group, Family Medicine. Service 2026-06-21 at office (POS 11). Received 2026-07-05.
Member
Resolved through the identity graph
- Member
- Sharon Dean
- Member ID
- none on golden record
- Date of birth
- 2005-09-11
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-423224
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by name and date of birth
- Plan
- CORE-HMO HMO group GRP-3474
- Coverage period
- 2021-02-01 to 2026-08-13
- Deductible
- $490.48 of $1,000.0049%
- Out-of-pocket maximum
- $658.20 of $2,000.0033%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3004199154
- Network
- Out of network
- Rendering NPI
- 5821975609
- Location
- Atlanta, GA · TIN 59-2183874
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 36415 | Venipuncture | — | 1 | 1 | $19.00 | $8.55 | — | — | DeniedCO204 |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $29.00 | $13.05 | — | — | DeniedCO204 |
| Totals | $48.00 | $21.60 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-992894
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001406; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-06-21: CORE-HMO (HMO), effective 2021-02-01, terms 2026-08-13. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Fail | CO204 | Billing provider 3004199154 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Lakeside Medical Group2026-06-21 17:11
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-05 05:44
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-001406; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-21: CORE-HMO (HMO), effective 2021-02-01, terms 2026-08-13. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Billing provider 3004199154 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.